Did That Vasectomy Work? Docs Turn to Mailed-In Samples
A newer approach to postvasectomy semen analysis (PVSA) may make it easier for men to undergo testing to confirm whether they are sterile — a step that often is skipped, which, in rare instances, can lead to unintended pregnancies.
A report in the March issue of Andrology describes a technique that “eliminates the need to evaluate a fresh specimen.” Instead of bringing a sample to a clinic or laboratory within 2 hours of collection, as current guidelines recommend, patients can store the sample with a preservative and mail it in using the regular postal service.
The new mail-in technique — adapted from HIV research — relies on sperm count to assess sterility, whereas existing recommendations call for checking sperm motility as well. In most cases, sperm count is so low that motility is irrelevant, said Ann A. Kiessling, PhD, director of the Bedford Research Foundation, a nonprofit research group in Bedford, Massachusetts, and a co-author of the new report.
Many men skip traditional PVSA, citing reasons such as being too busy or embarrassed or finding the process inconvenient.
Kiessling’s group said that they hope the ability to submit a specimen by mail would eliminate some barriers to PVSA.
“The problem is very few guys are willing to go back and leave a specimen,” Kiessling said.
The Bedford Research Foundation markets mail-in kits, which cost about $50, including shipping, analyzing, and reporting. The cost of the kit supports the lab, Kiessling said.
Some clinics already give patients the option of mail-in service. DrSnip, a vasectomy provider with locations in Portland, Oregon, and Seattle, Washington, offers mail-in semen testing. Kits are mailed to patients 8 weeks after the procedure.
“You can conveniently collect and submit your sample in the comfort and privacy of your home,” DrSnip says on its website. Then patients can drop off a prepaid box with their sample at a US Postal Service location.
Analyzing semen could eventually have applications beyond contraception, Kiessling said.
“The big picture for PVSA is to begin to develop a way to utilize information in semen to assess overall male health,” she said. Their group has started to look at whether semen analysis might shed light on conditions like prostatitis or prostate cancer or be considered during an annual physical, for example.
Demand for vasectomies has increased since the US Supreme Court overturned a federal constitutional right to abortion in June. A group at Cleveland Clinic recently reported that vasectomy consultations in July and August 2022 were up 22.4% over the same period the year before (142 vs 116) at their hospital network.
The Bedford lab, likewise, has seen an uptick in requests for postvasectomy testing, including by Planned Parenthood clinics, Kiessling said.
“It has always seemed a mystery that vasectomy was less often used for family planning than the far more invasive tubal ligation,” she said. “It is a matter of raising awareness and discounting the fears about sexual performance following vasectomy.”
Vasectomy does not immediately prevent pregnancy even when the procedure is successful, and in rare cases, the procedure may fail, which is why PVSA is recommended.
The mail-in kit includes a condom, a bottle of preservative, gloves, an absorbent-lined plastic box, a plastic bag, and a cardboard mailing carton. The approach is based on a technique that was developed to examine how semen transmits HIV.
“The need was to stabilize all the cells in a semen specimen without it coagulating,” Kiessling said. “One of our urology colleagues thought it might help his chronic problem of getting patients to return to the office — or a laboratory — to produce a semen specimen to ensure the vasectomy was a sterility success. Over time, it became clear that some patients really liked the option, and a few more urologists began to order the kits for their patients.”
The new paper examines data from 6096 men who underwent vasectomy from January 2011 through December 2018 and ordered a mail-in kit. About 89% of the men returned at least one kit for analysis. Approximately 95% had too few spermatozoa 12 weeks after surgery to warrant a need to check for motility. “This suggests that fewer than 5% of postvasectomy patients might need follow-up fresh semen analyses, greatly easing the logistical burden of PVSA,” the researchers said.
One pregnancy was reported after an initial sperm count of 155,600/mL 6 weeks after vasectomy, indicating the need for further testing. “The patient had not returned a second kit for a repeat analysis,” the study authors wrote.
Questions and Controversies
The reliability of PVSA using samples sent by mail, whether testing must be performed on a fresh specimen, and the reliability of other kits that allow patients to conduct PVSA themselves at home are among several controversies related to PVSA, according to a 2015 vasectomy guideline from the American Urological Association.
The inability to evaluate motility with mailed samples could be a limitation, said Ronald E. Christensen, MD, a retired family physician in Anchorage, who has studied how often patients follow up for PVSA.
“If you had sperm, you would want to know if they were alive,” Christensen said.
But a mailed specimen would be “better than none, I think,” as long as patients understand the need to follow through with subsequent specimens if occasional sperm are seen, he said.
Christensen looked at records from 551 patients and found that 42% of his patients did not return for 6-week, 3-month, or 1-year PVSA.
He tried one intervention where, after the procedure, he handed patients urine containers, instructions, and the date to return with a sample. It did not help. “I was trying to say, what can I do to improve my odds? Turned out: nothing,” Christensen said.
Jared Diederichs, BSc, MD, a family physician in Saskatoon, Saskatchewan, and colleagues asked patients about their reasons for not completing PVSA.
Some said that they were too busy or inconvenienced; others felt confident in the physician or the procedure’s success without PVSA.
“Efficacy rates for vasectomy have been proven to be high, with quoted early failure rates in the range of 0.3% to 9% and late failure rates in the range of 0.04% to 0.08%,” they noted.
A global survey of 78 clinicians published last year found that the possibility of legal action influenced their decisions to recommend semen analysis and that many told their patients about the risk for recanalization.
“Failure of vasectomy is every surgeon’s concern and two-thirds of the participants reported having had at least one failure,” the authors of the survey wrote. “There is the need for a large multi-center study that would assess serial PVSA over an extended period of time in a larger number of men. This would clarify various doubts related to timing and interpretation of PVSA and would also help us understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.”
The Bedford Research Foundation markets mail-in PVSA kits, and the cost of the kits supports the lab.
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